Tropical Health Matters

Special Summit of African Union on HIV and AIDS, Tuberculosis and Malaria (ATM), Abuja, took place in Nigeria, from 12-16 July 2013, and produced a declaration that stressed “Abuja Actions Toward the Elimination of HIV and AIDS, Tuberculosis and Malaria in Africa by 2030.”

The participants declared on 16 July 2013 that, “We, the Heads of State and Government of the African Union, meeting at a Special Summit of the African Union in Abuja, Nigeria, on 15 and 16 July 2013 focusing on the Theme: ‘Ownership, Accountability and Sustainability of HIV/AIDS, Tuberculosis (TB) and Malaria Response in Africa: Past, Present and the Future’ to review the progress made and the challenges faced in implementing the Abuja Declaration and Plan of Action on Roll Back Malaria (RBM) of 2000; the Abuja Declaration and Plan of Action on HIV and AIDS, Tuberculosis and Other Infectious Diseases (ORID) of 2001; and the Abuja Call for Accelerated Action Towards Universal Access to HIV and AIDS, Tuberculosis and Malaria Services in Africa by 2010″ agreed to undertake several key actions.

Some actions were integrated such as, “Ensure that strategies are in place for diversified, balanced and sustainable financing for health, in particular AIDS, TB and Malaria, development of strategic health investment plans and strategies for innovative financing, including from the private sector” While others were disease specific like the following for malaria:

• Strengthen the use of effective insecticides for control and elimination of malaria, including the use of dichlorodiphenyltrichloroethane (DDT), where necessary
• Intensify the use of Larval Source Management (LSM) where suitable for the control and elimination of Malaria
• Ensure that Malaria Rapid Diagnostic Tests (RDT) meet WHO procurement criteria, are quality-controlled and selected to meet local Malaria epidemiology
• Accelerate scale-up of the WHO “T3: Test, Treat and Track” Initiative by ensuring universal access to diagnostic, testing for all suspected malaria cases and quality-assured anti-malaria treatment for confirmed infections, and tracking the diseases through timely and accurate surveillance
• Maintain funding for, and uninterrupted supply of, life-saving malaria commodities to prevent resurgences of malaria that can occur rapidly with devastating loss of life

The summit was not an end in itself, but a benchmark. The Declaration refers to three previous Declarations against which current progress has been measured. Organizations like the African Leaders Malaria Alliance (ALMA) will continue to monitor malaria progress of all member countries who were in attendance. These commitments by endemic countries will go a long way to sustain the efforts to eliminate malaria.

The use of sulphadoxine-pyrimethamine (SP) intermittent preventive treatment of malaria in pregnancy (IPTp) has been offered in stable malaria transmission countries for over a decade.  As observations continued that SP resistance was growing in children treated for malaria, SP was dropped as a recommended treatment drug in all malaria-endemic countries in Africa.  Ironically SP is still commonly found in pharmacy and medicine shops in many countries.

While SP resistance in child treatment has been documented, studies directly testing this in pregnant women have not been designed due to the usual concerns about  the effect of medicines in pregnancy. Already the recommendation for IPTp excluded its use in the first trimester. What has been observed though not that SP does not work, but that its half-life or period of effectiveness has been reduced. Therefore WHO still recommends SP for IPTp, but more frequently.

The new guidelines call for SP as IPTp to be given at every focused antenatal care (FANC) visit after quickening. There are four FANC visits recommended and depending when a woman comes for her first FANC visit, she may be eligible for 3 or 4 monthly IPTp doses.

In order to prevent SP efficacy as used in IPTp from eroding further, there have been strong calls for stopping its use for treatment. This has proved challenging since SP may cost less that one US dollar per dose, while ACTs, if not available free in government clinics (if no stock-outs), cost up to $6-$8 for adult doses. No wonder there is an economic appear to continue to stock SP in private shops for sale as an antimalarial. Even in public clinics SP meant for IPTp may be used by staff when there are ACT stock-outs.

It would seem that most of our national health authorities believe more in the economic laws of supply and demand than in the technical guidelines of WHO. Otherwise SP would not be so widely available in shops. Whether private sector sales of SP are ignored by health authorities or actually tolerated by them, the result is still a threat to mothers and unborn children whose lives can be saved by maintaining the efficacy of SP and banning sales and inappropriate use of SP.  Courage to stand up to private sales is needed.

On a closing note, you will have noticed the picture of the SP packet attached here. It is produced by a Kenyan company and was found in a pharmacy in Malawi. The manufacturer is clearly hoping to rebrand its product. The pharmacist admitted though that few have been sold since pregnant women get SP free at ANC.

Fortunately the shop is not promoting this SP for treatment but instead sells a brand of artemether-lumefantrine. Even this newly repackaged SP product for home use is inappropriate as IPTp should be given as directly observed treatment by a health worker. We should not let such inappropriate use of SP be hidden behind clever packaging. National Malaria Programs and Drug Authorities must join hands to restrict SP use for IPTp.

This guest blog is re-posted from the course blog for Social and Behavioral Foundations of Primary Health Care. The lesson about health literacy pertains as much to malaria as it does to cholera and handwashing. We thank Elohor Okpeva for sharing these experiences.

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Source: Jimmy Nyambok/USAID

In September 2011, there was a cholera epidemic across several States in Northern Nigeria, notably Yobe and Borno States. The Federal and State health Ministries were certainly overwhelmed and ill-equipped to handle the challenge. Repeated outbreaks of preventable diseases are not uncommon.

The Centers for Disease Control and Prevention (CDC) describe cholera as a disease caused by the bacteria vibrio cholerae, rare in industrialized nations, yet on the increase in many other places including Africa. It is a life threatening disease but easily preventable.

As a nation, Nigeria pledged to fulfill the indices of the MDGs. The fourth index of the MDG elaborated in the child survival strategies lists health education as its component. Locally, the Federal Ministry of Health also developed the National health promotion policy.

Following the cholera outbreak of September 2011, an informal health education session in the pediatric clinic at the Umaru Shehu Ultramodern Hospital (Maiduguri, Nigeria) with focus on hygiene was undertaken by a corps’ Doctor. The women listened with rapt attention, often accompanied by incredible nods, as they were told the benefits and impacts of hand washing in curtailing the disease. It was an unfamiliar message.

The Nation’s leaders, health team and key affiliates must recognize the crucial role of health education in general public health. The maintenance of a healthy status begins with prevention and not clinical treatment. The advantages of disease prevention and consequent reduction in morbidity and mortality cannot be over-emphasized.

This guest blog has been re-posted from The blog by Chioma Anigbogu who is in our course, Social and Behavioral Foundations of Primary Health Care.
Malaria continues to severely burden many Sub-Saharan countries, including the nation of Burundi. In Burundi, 78% of the country lives in high or low transmission areas.  In this population, pregnant women are at greater risk of experiencing spontaneous abortions, low birth weight, neonatal deaths and even anemia due to malaria.  However, researchers have found that prevention treatment (Intermittent prevention therapy or IPT) during pregnancy can significantly reduce neonatal mortality and morbidity.

Image Source: http://www.msf.org.au/from-the-field/field-news/field-news/article/alarming-rise-in-malaria-infections-in-kayanza-province-burundi.html

The WHO has a three-pronged recommendation for the prevention of malaria, including IPT, distribution of insecticide treated nets (ITNs) and proper management of disease.  Burundi adopted an ITN policy in 2004 and has many in-country and international programs that distribute ITNs.  Burundi even reports 100% treatment coverage for tested malaria cases.  However, unlike some other African countries, Burundi has not adopted an IPT policy for malaria, leaving pregnant women and children extremely vulnerable.

Table Source: http://www.plosone.org/article/info:doi/10.1371/journal.pone.0009438

In 2011, the government of Burundi (GOB) developed the Global Health Initiative, in partnership with international organizations, that is aimed at reducing maternal, neonatal and child health disease. The GHI holds a specific tenet regarding the “prevention and treatment of malaria”.  In 2009 Burundi also received funds from the US- Agency for International Development (USAID) to complement already existing malaria activities.  These activities sometimes include IPT but there is no formal requirement or enforcement of the treatment. WHO suggests that confusion amongst health workers may contribute to the lack of recommendation for this preventative treatment.  A national policy that is developed and properly implemented would train health officials and workers in assuring that this treatment is integrated to the provision of services for women.

It would increase the overall health of the country and further bolster the work of other organizations such as Doctors without Borders and the Canadian Red Cross who are invested in Burundi’s malaria management. Adoption of this policy in Burundi will also reduce the negative impact of malaria, and may even reduce overall health spending by helping to maintaining better health for mothers and neonates.

In order to contribute your voice, leave a comment for the USAID (who works directly with Burundi), encouraging them to work with the Burundi government to adopt an IPT policy.

Photo Credit: Médecins Sans Frontières (Doctors without Borders)

IPT Table: http://www.plosone.org/article/info:doi/10.1371/journal.pone.0009438

The World Health Report 2013 entitled Research for Universal Health Coverage has been released. Since universal coverage has been a central Roll Back Malaria target since 2009, we have included below some of the mentions of studies and activities around malaria service provision and scaling-up.

The case for investing in research is made, in part, by demonstrating that scientific investigations really do produce results that can be translated into accessible and affordable health services that provide benefits for health… In one (example) a systematic review of survey data from 22 African countries showed how the use of insecticide-treated mosquito nets was associated with fewer malaria infections and lower mortality in young children. This evidence underlines the value of scaling up and maintaining coverage of insecticide-treated nets in malaria-endemic areas. (page xiv)

(Environmental risk factors) also contribute to the transmission of vector-borne diseases: malaria is associated with policies and practices on land use, deforestation, water resource management, settlement siting and house design. (Page 41).

By killing or repelling mosquitoes, insecticide-treated bed nets protect the individuals sleeping under them from malaria. By killing mosquitoes, they should also reduce malaria transmission in the community. Randomized controlled trials conducted in sub-Saharan Africa in a range of malaria endemic settings have provided robust evidence of the efficacy of ITNs in reducing malaria parasite prevalence and incidence and all-cause child mortality. Such trials showed that ITNs can reduce Plasmodium falciparum prevalence among children younger than five years of age by 13% and malaria deaths by 18%. (page 61)

(More research is needed because) In contrast with the findings of controlled trials, ITNs may be less effective in routine use because the insecticidal effect wears off, or nets may be used inappropriately or become damaged. The impact of ITNs, as used routinely, on malaria and childhood mortality is therefore uncertain.  (page 62)

As we can see from the World Health Report, malaria research has made a major contribution to our understanding of factors and effects of scaling up programs to try to achieve universal coverage.  As WHO recommends, more funding for health service coverage is needed, and malaria countries countries themselves need to contribute their own share in supporting their own research institutions.

“This is a scientific advance rather than a practical one,” said Dr. William Schaffner, of Vanderbilt University’s Medical School to the New York Times. So goes the fate of the latest in research reports on efforts to develop a malaria vaccine.  Prof. Schaffner goes on to explain that, “Giving multiple IV doses of any vaccine is also impractical because it requires sterile conditions, trained medical personnel and follow-up. IV drips are particularly hard to administer to children.”

It seems that every possible media outlet in the planet picked up on the fact that this intravenous dose of irradiated/killed malaria parasites was 100% effective. Most though did not see this as just one more step in understanding the long string of immunological research processes needed to come up with a vaccine that can actually work under real life field conditions.

Just last year, hopes crashed on a long-tested malaria vaccine known as RTS,S that had been through clinical trials in several African countries.  Not only did the vaccine need to be administered three times, but even then achieved limited effectiveness, though severe malaria appeared to have been reduced by around 50%. Just last year unfortunate results from monitoring showed that over time the vaccine lost the effectiveness it initially achieved.

It had been hoped that if this or another successful vaccine candidate could be ready for scale up, that it could be integrated into the existing child immunization programs of malaria endemic countries. Findings from recent Demographic and Health Surveys shown here remind us that even vaccines that have been routinely delivered to children for decades still have problems achieving adequate coverage.  Two of those depicted, DPT and Polio, like the RTS,S required three doses. This is a logistical and management challenge to be sure, but also a social, cultural and behavioral one.

The vaccine search goes on with several research reports appearing monthly on new findings about human immune responses to malaria in it various forms.  We trust that one day a vaccine that is effective as the existing child immunizations will come to market. Even then, as we can see from ‘normal’ vaccine coverage rates, we will not be able to rely totally on a malaria vaccine for preventing the disease. Of course none of the existing preventive measures reaches all people, and hence our malaria elimination strategies must continue to include a combination of approaches.